Provider Demographics
NPI:1770687998
Name:PEARSON, RANDOLPH LESTER (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:LESTER
Last Name:PEARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E MICHIGAN AVE
Mailing Address - Street 2:SUITE 245
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912
Mailing Address - Country:US
Mailing Address - Phone:517-364-5710
Mailing Address - Fax:
Practice Address - Street 1:1200 E MICHIGAN AVE STE 245
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1897
Practice Address - Country:US
Practice Address - Phone:517-364-5710
Practice Address - Fax:517-364-5718
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045048207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4255429Medicaid
MI4255429Medicaid
MIA76066Medicare UPIN